In general, a clinical document used in the medical field is a document of a patient's medical record and contains the patient's symptoms, a doctor's diagnosis and prescription, etc. Here, medical terms or medical data used in the clinical document to represent medical records are used differently by each medical worker or medical institution.
The medical terms or medical data require fast and accurate processing for their use and are required to ensure semantic and functional interoperability with other medical workers and support staff beyond one medical worker's use. In order to maintain these properties, it is necessary to construct a structural terminology system in the medical field so as to more easily obtain, collect, transfer, and process information contained in the clinical document.
With an existing data model-based terminology system, it is insufficient to achieve the above-mentioned object, and thus a supporting tool for structured data input is required. Furthermore, it can be said that the development of a terminology system for supporting the sharing of a clinical decision support system and an electronic health record is necessary.
First, it is necessary to clarify the concepts of medical terms used in the clinical document. This is because different terms are used for the same concept between medical workers, which makes it difficult to ensure smooth communication of information.
For this purpose, a terminology system which includes a set of medical concepts used in a specific medical field, the definition of each concept, the term for each concept, the relationship between concepts, etc. is being developed, and examples of the terminology system include a reference terminology, an interface terminology, etc. depending on its purpose and characteristics.
A reference terminology system is a set of standardized representations of medical concepts and their interrelationships and includes SNOMED CT, RxNorm, NCI Thesaurus, ICNP, etc.
Although there is the reference terminology system which is a set of standardized representations of medical concepts, local terms used by medical workers in various fields in each hospital are different, and thus a mapping operation is required to make up for the difference. In particular, it is necessary for the interface terminology to interface between the medical workers and the reference terminology system, and thus it is preferable that the interface terminology be configured based on the reference terminology system.
In order to solve the above-described problems, the present applicant discloses a terminology editing system based on a reference terminology, which constructs a terminology system in which the medical terms used in the medical institution are structured with entities and relations using a reference terminology system, in Korean Patent Application No. 10-2010-0033967, filed Apr. 13, 2010 (hereinafter, prior art 1).
When using the above prior art 1, it is possible to construct the interface terminology in the medical field to enable better communications between medical doctors or medical workers. However, the terminology system of the above prior art 1 can only support the structuralization of the concepts of terms in an accurate and systematic manner.
However, although the concepts of medical terms are structuralized, it is necessary to determine how the concepts are used in order to clearly understand the medical data for medical records). For example, if it is determined that the blood pressure is an arterial blood pressure and if it is whether the blood pressure is a systolic blood pressure or diastolic blood pressure, it is necessary to describe the condition in which the blood pressure is measured. Moreover in order to more clearly describe the patient's symptoms or the doctor's diagnosis, it is necessary to describe in more detail the severity, location, etc.
That is, the medical data should contain information on the context in which the data is created as well as the medical terms (or concepts). However, even in the same medical term, the context information may vary according to the medical worker or medical institution. A primary hospital may measure the blood pressure and describe only the values of the systolic and diastolic blood pressures. However, a tertiary hospital may further describe in detail a measurement means, a measurement site, a measurement posture, etc as well as the values of the systolic and diastolic blood pressures. This is because there may be subtle differences in the measurement results depending on the measurement conditions.
Therefore, it is necessary for the interface terminology system, which is designed such that a medical professional and a clinical support specialist can more easily obtain, collect, transfer, and process the information contained in the clinical document, to contain the context information to be processed and to have a supporting tool for structured data input such that the context information can be easily input in the medical field.